Author: ijahns

The Medicalization Debate

The healthcare field has been one of the fasted growing industries across the globe in recent decades as researchers and medical professionals continue to search for new and improved forms of care. Advancements in new technology, drugs, and our understanding of various health-related conditions are constantly being made and shaping our perception of the world we live in. As Robert Crawford points out in his publication Health as a Meaningful Social Practice, medical policies, forms of treatment, and the way in which we understand different medical conditions influences how we perceive ourselves within the social sphere of society (Crawford, 2006). This relationship between healthcare and social practices becomes especially important when discussing the concept of medicalization. Medicalization refers to the process in which non-medical problems become redefined within the scope of medicine and are treated as such, according to Peter Conrad from Brandeis University (Conrad, 1992). Medicalization has become a point of focus recently as improper identification of an issue as being medical-related could have harmful effects on both patients and society as a whole. Researcher Erik Parens points out that medicalization itself is not necessarily a bad thing, but rather it becomes an issue when the medicine oversteps its limitations (Parens, 2013).

Emilia Kaczmarek describes four major risks that may arise in the case of over-medicalization. First, over-medicalization may have a negative impact on patient health as it promotes excessive treatment that could lead to undesirable side effects. Next, over-medicalization has an effect on the economy as it can promote the misplacement of both public and private funds. Third, over-medicalization can have important psychological implications by stigmatizing certain individuals or their “condition” as being sick and restrict personal freedom through pressures to alter one’s behavior to the standards of society. Finally, over-medicalization overlooks the different social, political, and interpersonal relationships that may play a role in the problem a person is facing (Kaczmarek, 2018). Excessive medicalization can be seen in a number of different examples, such as ADHD, women and childbirth, menopause, erectile dysfunction, sleep disorders, and much more. In each of these cases, the condition is viewed through a biological lens that causes other contributing factors to be overlooked and an emphasis to be placed on medications and other medical treatments. This reading will be focusing on the influence medicalization has had on ADHD specifically and the impact this has had on the most vulnerable patient population: children.

A Snapshot of ADHD in the U.S.

The Center for Disease Control and Prevention describes ADHD as a neurodevelopmental disorder that is commonly diagnosed during childhood and persists through adulthood (Center for Disease Control and Prevention [CDC], 2022). The condition is typically associated with an inability to pay attention, difficulty controlling impulsive behaviors, and being excessively active. In the U.S., it is estimated that around 6 million children are currently diagnosed with ADHD with over 265,000 of these diagnoses occurring in children between the ages of three and five (CDC, 2022). Of this patient population, 62% were consistently taking ADHD medication while 47% were receiving behavioral treatment for a combined 77% of children with ADHD taking some form of treatment. Behavioral treatment for ADHD does not have an impact on the core symptoms experienced by these patients, but rather it involves teaching children various coping strategies in order to control their symptoms. Behavioral therapy is comprised of two main components in order to help children manage the various symptoms of ADHD. The first is what is known as “parent training” that focuses on teaching children how to control their impulsive behavior. This portion of therapy involves both the children and their parents and provides parents with different strategies in dealing with their child’s behavior. The second form of behavioral therapy deals with what is known as “executive functions.” These executive functions are a set of skills that enable a child with ADHD to better manage their time, stay organized, and plan different tasks (Miller, 2022).

Although, nearly half of all diagnosed children are involved in ADHD behavioral therapy, treatment in the form of medication is much more common and also more relevant to the topic of medicalization. ADHD medication primarily involves stimulants such as methylphenidate or amphetamine. These stimulants, which include well-known brand-name drugs like Adderall and Concerta, are the most commonly used ADHD medications and are often varied by dosage depending on the patient’s needs. In general, long-term use of stimulants can have adverse health effects, primarily on the cardiovascular system, as it can lead to chronic high blood pressure, increased heart rate, and heart failure (Losch, 2023). As a result, concern has grown regarding prescribing ADHD medication to children, especially since some may begin taking these drugs as young as three years old.

Only a small fraction of children with ADHD have outwardly hyperactive symptoms.

ADDitude Magazine

The Medicalization of ADHD and the Risks it Poses to Children

With nearly 1 in 11 children in the U.S. currently having an ADHD diagnosis and this rate of instance steadily increasing since 1997, it calls into question the reason for this growing prevalence (Lanham, 2023; CDC, 2022). Are more people in the U.S. being affected by ADHD, is improved testing allowing for more accurate detection of ADHD, or is our understanding and perceptions of ADHD changing and causing a greater number of people to fall under what society categorizes as ADHD? This is where the topic of medicalization becomes relevant. The over-medicalization of ADHD has the potential to increase the rate of diagnosis in children and, as a result, increase the number of children receiving medicated treatment. It is possible that more people are not actually suffering from ADHD, but rather societal pressures, expectations, and norms are shaping how we view the condition. The structure of the U.S. education system requires students to sit at their desk for prolonged periods of time and often does not involve a lot of physical movement. When a kid fails to adhere to expectations that they remain attentive and non-disruptive for these prolonged periods of time, the first assumption may be that they are suffering from ADHD since an inability to focus and control impulsive behavior is associated with this condition. In today’s world, there is a much greater public awareness of ADHD that has caused it to become de-stigmatized, which could explain the growing numbers of cases. The inability of children to focus in a classroom setting may have previously been thought to be related more to the energetic nature of children, but increased public awareness has created an over-emphasis on the correlation between ADHD and hyperactivity in children, leading to far more diagnoses.

The reason that the changing perception of ADHD in society, leading to more supposed cases, is important again comes down to the emphasis on using of ADHD medication to treat the disorder. The nature of stimulants, like ADHD medications, can create a number of different side effects in those taking them. ADHD medications have been known to cause sleep problems, decreased appetite, delayed growth, frequent headaches and stomachaches, irritability as the drug wears off, tics, and changes in mood (Boorady, 2022). This has caused great concern in prescribing children these medications as they are undergoing significant neurological, hormonal, and physical development and the long-term impact these effects can have on this development are mostly unknown as most studies often involve non-human subjects due to the many ethical concerns of experimenting on humans (Volkow, 2008). The fact that the experience and severity of ADHD often varies among individuals can lead to an increase in the number of patients being diagnosed with and receiving treatment for ADHD as well. According to a study published in the National Library of Medicine, there is not a single pathophysiological entity that causes ADHD, but rather multiple risk factors work together to promote the condition we know as ADHD (Curatolo, 2010). This creates the potential for a number of different neurological conditions and features to be classified as having ADHD implications when they may not necessarily cause ADHD themselves and, therefore, more children may qualify for an ADHD diagnosis. This prevents the development of a biologically based test for diagnosing children and instead diagnosis relies on the clinician’s perception of the child’s behavior and parent description.

Conclusion

The over-medicalization of various disorders and conditions has major implications on patient health and overall quality of life. Viewing these disorders with an emphasis on their biological and medical applications opposed to a more comprehensive understanding of the different factors that may contribute to them may negatively affect the patients living with these problems. This becomes more relevant for disorders that are typically diagnosed in children as there could be many long-term effects that have the potential to adversely affect the patient later in life. ADHD is one of these conditions that generates a great deal of concern, especially since the main form of treatment for ADHD in children is prescription drugs. The over-medicalization of ADHD has the potential to increase incidence of diagnoses, and result in a greater number of children taking these prescriptions. ADHD, like many other overly medicalized conditions, lacks a strong biological basis where biological markers can be used to make a diagnosis. Instead, clinicians rely on observed behavior of the patient and descriptions from parents to make the decision of whether or not the child should be treated with a strong chemical compound. Understanding the role that medicalization has on our perception of conditions like ADHD and how this can influence our decisions is key in being able to prevent excessive treatment in vulnerable patients that may not necessarily require treatment.

Works Cited

Behavioral treatments for kids with ADHD. Child Mind Institute. (2023, January 25). Retrieved March 28, 2023, from https://childmind.org/article/behavioral-treatments-kids-adhd/

Carpiano, R. M. (2001). Passive medicalization: The case of Viagra and erectile dysfunction. Sociological Spectrum, 21(3), 441–450. https://doi.org/10.1080/027321701300202082

Centers for Disease Control and Prevention. (2022, August 9). ADHD throughout the years. Centers for Disease Control and Prevention. Retrieved March 28, 2023, from https://www.cdc.gov/ncbddd/adhd/timeline.html

Centers for Disease Control and Prevention. (2022, August 9). Data and statistics about ADHD. Centers for Disease Control and Prevention. Retrieved March 28, 2023, from https://www.cdc.gov/ncbddd/adhd/data.html

Centers for Disease Control and Prevention. (2022, August 9). What is ADHD? Centers for Disease Control and Prevention. Retrieved March 28, 2023, from https://www.cdc.gov/ncbddd/adhd/facts.html#:~:text=ADHD%20is%20one%20of%20the,)%2C%20or%20be%20overly%20active.

Conrad, P. (1992). Medicalization and Social Control. Annual Review of Sociology, 18(1), 209–232. https://doi.org/10.1146/annurev.so.18.080192.001233

Crawford, R. (2006). Health as a meaningful social practice. Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine, 10(4), 401–420. https://doi.org/10.1177/1363459306067310

Curatolo, P., D’Agati, E., & Moavero, R. (2010). The neurobiological basis of ADHD. Italian Journal of Pediatrics, 36(1), 79. https://doi.org/10.1186/1824-7288-36-79

General prevalence of ADHD. CHADD. (2022, October 20). Retrieved March 28, 2023, from https://chadd.org/about-adhd/general-prevalence/#:~:text=5.1%20million%20children%20(8.8%25%20or,%E2%80%9317%20(1%20in%2010)

Is there an increase in ADHD? CHADD. (2019, July 11). Retrieved March 28, 2023, from https://chadd.org/adhd-weekly/is-there-an-increase-in-adhd/#:~:text=Greater%20public%20and%20professional%20awareness,and%20getting%20treatment%20for%20children.

Kaczmarek, E. (2018). How to distinguish medicalization from over-medicalization? Medicine, Health Care and Philosophy, 22(1), 119–128. https://doi.org/10.1007/s11019-018-9850-1

Mayo Foundation for Medical Education and Research. (2023, January 25). Adult attention-deficit/hyperactivity disorder (ADHD). Mayo Clinic. Retrieved March 28, 2023, from https://www.mayoclinic.org/diseases-conditions/adult-adhd/diagnosis-treatment/drc-20350883#:~:text=and%20certain%20medications-,Treatment,they%20don’t%20cure%20it.

PARENS, E. R. I. K. (2011). On good and bad forms of medicalization. Bioethics, 27(1), 28–35. https://doi.org/10.1111/j.1467-8519.2011.01885.x

Side effects of ADHD medication. Child Mind Institute. (2023, January 25). Retrieved March 28, 2023, from https://childmind.org/article/side-effects-of-adhd-medication/

Staff, P. R. C. (2022, June 7). The long-term consequences of stimulant use. Pinelands Recovery Center of Medford. Retrieved March 28, 2023, from https://www.pinelandsrecovery.com/the-long-term-consequences-of-stimulant-use/

Volkow, N. D., & Swanson, J. M. (2008). Does childhood treatment of ADHD with stimulant medication affect substance abuse in adulthood? American Journal of Psychiatry, 165(5), 553–555. https://doi.org/10.1176/appi.ajp.2008.08020237

Better Medical Resources ≠ Better Medical Care

Over the past century, humans have made incredible progress in our understanding of medical ailments and how to properly provide treatment to those affected by them. Major advancements in the development of technology and different medications have played a significant role in this growth of the medical field. With instruments that allow us to better study human pathogens, screen for various diseases, provide extremely precise care, and much more, we are living in a world in which people of the past never would have thought could exist. Within about 120 years, we have progressed from a nation where an average of one in every 40 Americans die annually to a significantly lower rate of about one in every 120 Americans and, although this average rate is affected by numerous factors, discoveries and advancements in the medical field have played a tremendous role in its steady improvement (Penn Wharton, 1). One cannot deny the benefits technology has provided us in our quality and duration of life, however, technology has also been a driving force of widening disparity within our healthcare system. Despite continuous breakthroughs in medical care through the use of technology, many of these new forms of care remain inaccessible to a majority of the population and distort our views of the medical world. The diabetic population clearly illustrates this growing disparity within the healthcare system and demonstrates our need to improve current policies to better utilize the incredible achievements we have made as a species.

 “Living with diabetes means people usually don’t realize or understand what you’re living with”

Nick Jonas

What is Diabetes and How Does Technology/Medication Play a Role?

Type 1 diabetes is an autoimmune disease in which the immune system irreversibly destroys the insulin-producing beta cells of the pancreas. Insulin is the hormone released by our body in response to the consumption of food as it allows glucose within the bloodstream to be taken up by cells for the production of ATP. For a diabetic that has lost the ability to produce insulin, that glucose will remain in the bloodstream and prevent cells from producing energy for the body while leading to many negative effects, such as the blood becoming acidic, loss of vision, damaged nerves, kidney failure, amputation of limbs, and much more. Type 1 diabetes is a chronic condition, meaning once a person is diagnosed, they will live with the disease for the rest of their life. Furthermore, it is a condition that requires 24/7 monitoring and care, often leading to drastic changes within a person’s everyday life and causing their whole world to revolve around this medical condition. Just over 100 years ago, a diagnosis of diabetes was a death sentence in which a child, as type 1 diabetes is primarily diagnosed in early childhood, would not be expected to live more than 3 years (Distiller, 3). However, medical discoveries and major advancements in technology have provided patients with the ability to live full and high quality lives as we now have access to synthetic insulin, insulin pumps, continuous glucose monitors (CGMs), improved education, and more. It is impossible to deny the tremendous amount of good these technological and medical achievements have made in the lives of people living with such a life-altering condition, however, this also begs the question of how there can be such large disparities in the quality of life for a disease we now know so much about and have incredible resources for managing. 

“We have the greatest hospitals, doctors, and medical technology in the world – we need to make them accessible to every American.”

Barbara Boxer

Barriers to Medical Care and our Misconceptions of Diabetes Management 

In today’s world, we have access to insulin pumps that will automatically deliver precise amounts of insulin, CGMs that allow a person to know their exact blood sugar at any given moment without the need for finger pricks, inhalable glucagon that saves lives when used during hypoglycemic emergencies, and so much more. So why is diabetes still such a hard disease to manage? Aside from the fact that diabetes is an irregular disorder that may still have complications regardless of near-perfect management, the primary barrier to effective diabetes management remains access to supplies. A majority of diabetics struggle to access the life-saving medical supplies we have available that transform a burdensome and debilitating condition into one that is manageable. This disparity in access is due to a number of factors, however, the main barrier remains the cost of insulin and diabetes technology. While various technologies such as insulin pumps and CGMs greatly improve a person’s ability to manage diabetes and can have life-changing results, it is still possible to manage one’s condition without these technologies through the use of traditional insulin syringes and finger pricks. Insulin, however, is required for a person with diabetes as they cannot survive without it. As previously mentioned in this discussion, insulin is needed to take up glucose from the blood for energy production and when insulin is not present, the body will turn to other sources for energy. The method for providing energy that the body primarily turns to is a process in which fat is converted into energy, however, unlike the regular process involving glucose, this secondary process produces ketones as a byproduct. This results in the buildup of ketones within the blood, turning it acidic and leading to a life threatening condition called diabetic ketoacidosis (DKA). Aside from this dangerous condition, sustained levels of elevated blood sugar can also lead to the many debilitating long term consequences that were mentioned earlier, such as loss of vision, kidney function, feeling in extremities, and limbs. This is why insulin is essential for not only living a high quality life, but for survival itself. With over 1 million diabetics having to ration their life saving insulin everyday, our healthcare system needs a dramatic change (Norton, 1). 

Why is Insulin so Expensive?

According to Ashley Driesbach’s research, a study conducted in 2018 found that on average it costs about $2.28-$3.42 to produce a single vial of human insulin and a year’s worth of insulin only costs $48-$71 per diabetic patient (Driesbach, 8). So how can so many people still be struggling to afford their life saving medication? The answer comes down to the lack of regulations surrounding the major insulin-producing companies. Insulin is manufactured by just three major companies: Eli Lilly, Novo Nordisk, and Sanofi (Martínez, 1). These companies face very few regulations in how they manufacture and sell their product, which is what allows them to increase the selling price of insulin to about $25-$100 per vial for older insulins and $174-$300 per vial for newer insulins merely for the sake of profits. Although insurance may help with some of the cost, many people with insurance are still forced to pay a hefty amount out of pocket and those without insurance are often left helpless (SingleCare, 6). A study from 2019 and 2020 found that insured diabetics were still forced to pay an average of $35 for a 30-day supply of insulin while many others are forced to pay more (Lovelace, 11). Recent studies have also shown that this inflation crisis is only getting worse as insulin prices have increased by about 600% over the last 20 years (Inskeep, 1). The cost of insulin has proven to be a major barrier to diabetics living a full and healthy life and as this crisis continues to worsen, leading to the deaths of people around the globe that could have been prevented with access to insulin, many are wondering what can we do as a society to solve this problem.

“Universal coverage, not medical technology, is the foundation of any caring health care system.”

Richard Lamm

What needs to be done

Reducing the growing disparity diabetic patients face in accessing their medical supplies and technology is something that needs to happen, but there is no clear and simple solution for achieving this. From reading the current research and hearing the life experiences of diabetics around the world, I believe our best chance at reducing this disparity is reducing the cost of diabetes supplies. Although there may be other factors that make accessing medical supplies difficult for a diabetic, cost of insulin and other diabetes supplies remains the most significant barrier as insulin pumps themselves cost an average of $4,500-$6,500 (Vaida, 16). To help alleviate some of the financial burden faced by millions of Americans living with diabetes, we must form new policies that regulate these costs, whether that be introducing policies to provide greater healthcare coverage for uninsured patients, policies that require insurance companies to cover more of the costs for things like insulin and insulin pumps, or policies that regulate the major insulin-producing companies and how much they can sell their product for. It is difficult to say when policies such as these may become possible or if they will ever become possible, as the US is still a long way away from adopting universal healthcare and pharmaceutical companies and insurance companies have remained relatively free to make decisions that directly benefit them at the expense of their “customers” for decades. Whether or not policies such as these are achieved in the US someday, we must continue to raise awareness of the issue as healthcare costs continue to be a widespread epidemic that plagues non only diabetics, but millions of Americans affected by other conditions as well.

Works Cited

Catastrophic spending on insulin in the United States, 2017–18. (n.d.). Retrieved February 21, 2023, from https://www.healthaffairs.org/doi/10.1377/hlthaff.2021.01788

Centers for Disease Control and Prevention. (2022, December 30). Types of insulin. Centers for Disease Control and Prevention. Retrieved February 20, 2023, from https://www.cdc.gov/diabetes/basics/type-1-types-of-insulin.html

Distiller L. A. (2014). Why do some patients with type 1 diabetes live so long?. World journal of diabetes, 5(3), 282–287. https://doi.org/10.4239/wjd.v5.i3.282

Drugmakers that dominate the world’s insulin market must scale up access efforts globally. Access to Medicine Foundation. (n.d.). Retrieved February 20, 2023, from https://accesstomedicinefoundation.org/news/how-the-dominant-global-insulin-producers-must-scale-up-access-efforts-to-reach-people-with-diabetes-worldwide#:~:text=The%20three%20companies%20that%20dominate,%2Dincome%20countries%20(LMICs).

Facts. JDRF. (n.d.). Retrieved February 20, 2023, from https://www.jdrf.org/t1d-resources/about/facts/#:~:text=Some%201.45%20million%20Americans%20are%20living%20with%20T1D.&text=64%2C000%20people%20are%20diagnosed%20each%20year%20in%20the%20U.S.&text=2.1%20million%20people%20in%20the,to%20have%20T1D%20by%202040.

Inskeep, S., & Aubrey, A. (2022, September 12). Insulin costs increased 600% over the last 20 years. states aim to curb the price. NPR. Retrieved February 20, 2023, from https://www.npr.org/2022/09/12/1122311443/insulin-costs-increased-600-over-the-last-20-years-states-aim-to-curb-the-price#:~:text=The%20price%20of%20insulin%20remains,patients%20ration%20this%20lifesaving%20drug.

NBCUniversal News Group. (2022, July 24). Why is insulin still so expensive for diabetes patients in the U.S.? NBCNews.com. Retrieved February 20, 2023, from https://www.nbcnews.com/health/health-news/why-insulin-so-expensive-diabetes-united-states-rcna39295

NBCUniversal News Group. (n.d.). Insulin costs will be capped in 2023, but most people with diabetes won’t benefit. NBCNews.com. Retrieved February 20, 2023, from https://www.nbcnews.com/health/health-news/insulin-cost-cap-people-diabetes-no-benefit-rcna58165

Over a million Americans are rationing insulin due to high cost. (n.d.). Retrieved February 21, 2023, from https://www.usnews.com/news/health-news/articles/2022-10-18/over-a-million-americans-are-rationing-insulin-due-to-high-cost

PPI, W. (2018, December 19). Mortality in the United States: Past, present, and future. Penn Wharton Budget Model. Retrieved February 20, 2023, from https://budgetmodel.wharton.upenn.edu/issues/2016/1/25/mortality-in-the-united-states-past-present-and-future#:~:text=The%20United%20States%20has%20enjoyed,of%20more%20than%20two%20thirds.

Team, S. C. (2023, February 8). How much does insulin cost? The Checkup. Retrieved February 20, 2023, from https://www.singlecare.com/blog/insulin-prices/#:~:text=A%202018%20study%20estimated%20that,133%20per%20patient%20per%20year.

Vaida, B. (n.d.). What diabetic supplies do I need, and what are the costs? – goodrx. Retrieved February 21, 2023, from https://www.goodrx.com/conditions/diabetes/supplies-for-diabetics

Xplore. (n.d.). Medical Technology quotes. BrainyQuote. Retrieved February 20, 2023, from https://www.brainyquote.com/topics/medical-technology-quotes